It will be the objective of this study to investigate three factors fundamental to the surgical decision making process: 1) basic attitudinall differences in tendency to operate between American, Canadian and English surgeons, and the magnitude of these differences as related to the performance of 7 elective procedures, 2) a determination of various educational, financial and organizational factors and their possible effect on surgical judgement, and 3) the reliability of clinical surgical judgement and its effect on the current implementation of elective surgery second opinion programs. To examine these issues, four vignettes, for each of seven different disease processes, have been developed by panels of surgical specialists from the Johns Hopkins Hospital. These case histories will be mailed to randomly selected Board certified surgeons or their equivalent from selected states, provinces and health districts in the U.S., Canada and England, respectively. The areas to be chosen will be from among those which have data systems available that contain known operative rates for the procedures under study. The surgeons are asked to indicate whether they would (YES) or would not (NO) perform the procedure under question independent of economic considerations. The proportion of YES responses for each separate case history will be determined. This will provide a measure of the tendency to operate (basic attitudinal differences) for each country. The relationship between the educational, financial, and organizational factors and a surgeon's willingness to perform elective surgery will be examined. The extent of agreement/disagreement among the surgeons for each case vignette will provide an indication of the reliability of clinical decision making with regard to elective operations.